When Your Inhaler Isn't Enough: Understanding Moderate to Severe Asthma

For millions of Americans, asthma is a manageable inconvenience. A puff from an inhaler before exercise, maybe a daily controller medication, and life goes on more or less normally. But for a significant number of people — roughly 5 to 10% of the estimated 25 million Americans with asthma — the reality is very different.

Their inhaler doesn't keep things under control. They still wake up coughing in the middle of the night. They still cancel plans because they can't predict when their breathing will cooperate. They've tried multiple medications, seen specialists, adjusted doses, and still find themselves reaching for their rescue inhaler far more often than they should.

This is what it means to live with moderate to severe asthma — and if it sounds familiar, this guide is for you. We'll cover what moderate to severe asthma actually is, how it differs from milder forms, why some people's asthma doesn't respond to standard treatment, what options are currently available, and what clinical research is doing to find better answers.

What Is Asthma?

At its most basic level, asthma is a chronic condition that affects the airways — the tubes that carry air in and out of your lungs. In a person with asthma, these airways are persistently inflamed and more sensitive than normal to certain triggers. When exposed to a trigger, three things happen:

Inflammation increases. The lining of the airways swells, narrowing the space available for air to pass through.

Muscles tighten. The bands of muscle surrounding the airways contract (a process called bronchoconstriction), squeezing them even tighter.

Excess mucus is produced. The airways produce more mucus than usual, further clogging the already narrowed passages.

The result is the symptoms most people associate with asthma: wheezing, shortness of breath, chest tightness, and coughing. These symptoms can range from barely noticeable to severe enough to require emergency treatment.

What makes asthma different from conditions like COPD is that the airway narrowing is typically reversible — either on its own or with medication. A person having an asthma attack can use a rescue inhaler (usually albuterol) and feel their airways open within minutes. This reversibility is one of the defining features of asthma, though in severe or long-standing cases, some degree of permanent airway change can occur.

How Asthma Severity Is Classified

Not all asthma is the same. Doctors classify asthma severity based on how frequent and intense symptoms are before treatment begins, and then assess how well those symptoms are controlled once treatment is underway.

The standard classification system uses four levels:

Mild intermittent. Symptoms occur no more than twice a week. Night-time symptoms occur no more than twice a month. Lung function is normal between episodes. Flare-ups are brief and don't significantly affect daily activities.

Mild persistent. Symptoms occur more than twice a week but not daily. Night-time symptoms occur more than twice a month. Flare-ups may start to affect daily activities.

Moderate persistent. Symptoms occur daily. Night-time symptoms occur more than once a week. Flare-ups affect activity levels and may last several days. A rescue inhaler is needed daily or almost daily. Lung function is reduced compared to predicted normal values.

Severe persistent. Symptoms are continuous or near-continuous throughout the day. Night-time symptoms are frequent. Physical activity is significantly limited. Flare-ups are frequent and can be severe. Lung function is substantially reduced.

There's an important distinction between asthma severity and asthma control. Severity describes the underlying nature of the disease. Control describes how well symptoms are being managed with treatment. A person with moderate persistent asthma might achieve good control with the right medications — or they might not, in which case their asthma would be described as "uncontrolled" despite treatment.

It's this second group — people whose asthma remains uncontrolled despite appropriate treatment — that represents one of the biggest challenges in asthma care today.

What Does "Uncontrolled Asthma" Actually Mean?

You might be told your asthma is "uncontrolled" or "not well controlled." But what does that actually look like in practice?

Doctors generally consider asthma to be not well controlled if, despite taking prescribed medications correctly, you experience any of the following:

Daytime symptoms more than twice a week
Waking up due to asthma more than twice a month
Needing your rescue inhaler more than twice a week (outside of exercise)
Any limitation on normal daily activities due to asthma
Reduced lung function on spirometry testing
One or more exacerbations (flare-ups) requiring oral corticosteroids in the past year

If several of these apply to you, your asthma is likely not well controlled — regardless of what medications you're currently taking. This doesn't mean you're doing something wrong. Some people's asthma is inherently more difficult to manage, and the reasons for that are complex.

Why Some People's Asthma Is Harder to Control

When asthma doesn't respond adequately to standard treatment, there are several possible explanations. Understanding why is the first step toward finding a better approach.

The medication isn't being used correctly

This is more common than most people realise. Inhaler technique matters enormously — studies have shown that a significant percentage of people use their inhalers incorrectly, which means they're not getting the full dose of medication into their lungs. If your asthma seems uncontrolled, it's worth having your doctor or pharmacist watch you use your inhaler and correct any issues with technique.

The diagnosis isn't quite right

Some conditions can mimic asthma or coexist with it, including vocal cord dysfunction, gastroesophageal reflux (GERD), chronic sinusitis, anxiety-related breathing patterns, and cardiac conditions. If these aren't identified and addressed, asthma treatment alone won't fully resolve symptoms.

Ongoing trigger exposure

If you're continuously exposed to something that triggers your asthma — allergens at home (dust mites, pet dander, mould), workplace irritants, or air pollution — no amount of medication may be enough to fully control symptoms while the exposure continues.

Underlying inflammation type

Not all asthma inflammation is the same. Doctors increasingly recognise different "phenotypes" (observable characteristics) and "endotypes" (underlying biological mechanisms) of asthma. The two major inflammatory patterns are:

Eosinophilic (Type 2) inflammation. Driven by a type of white blood cell called eosinophils, this pattern often responds well to corticosteroids and is associated with allergic triggers. However, in severe cases, even high-dose corticosteroids may not be enough.

Non-eosinophilic inflammation. This includes neutrophilic asthma and other patterns that don't respond as well to corticosteroids. People with this type of inflammation may find that increasing their steroid dose doesn't improve symptoms — because the inflammation driving their asthma isn't the type that steroids effectively target.

Understanding which type of inflammation is driving your asthma can help your doctor choose more targeted treatments, but this assessment isn't always done routinely.

The disease itself is severe

Some people simply have a more aggressive form of asthma. Their airways are more reactive, more prone to inflammation, and more resistant to standard treatments. This isn't a failure of effort or compliance — it's a reflection of the biological nature of their disease.

Common Triggers for Asthma

While the underlying cause of asthma is chronic airway inflammation, day-to-day symptoms are often triggered or worsened by specific exposures. Common triggers include:

Allergens. Dust mites, pollen, mould, pet dander, and cockroach waste are among the most common allergic triggers. For people with allergic asthma, exposure to these substances causes the immune system to overreact, worsening airway inflammation.

Respiratory infections. Colds, flu, and other viral infections are one of the most common triggers for asthma flare-ups. The infection causes additional inflammation in the airways, on top of the chronic inflammation already present.

Air quality. Outdoor air pollution (vehicle exhaust, industrial emissions, wildfire smoke) and indoor pollutants (cleaning products, strong perfumes, cooking fumes, tobacco smoke) can all provoke symptoms.

Weather changes. Cold, dry air is a well-known trigger. Sudden changes in temperature or humidity, thunderstorms (which can disperse pollen), and very hot, humid conditions can all worsen asthma.

Exercise. Physical activity — particularly in cold or dry air — can trigger bronchoconstriction in many people with asthma. This is sometimes called exercise-induced bronchoconstriction and can occur even in people whose asthma is otherwise well controlled.

Stress and strong emotions. Emotional stress, anxiety, laughing, or crying can trigger breathing changes that provoke asthma symptoms in some people.

Medications. Certain drugs can worsen asthma in susceptible individuals, including aspirin, NSAIDs (like ibuprofen), and beta-blockers.

Identifying and minimising exposure to your specific triggers is an important part of managing asthma, though for many people with moderate to severe disease, trigger avoidance alone isn't sufficient.

Current Treatment Options for Asthma

Asthma treatment follows a stepwise approach — starting with the least amount of medication needed to control symptoms and stepping up if control isn't achieved.

Step 1: Rescue Inhalers

Almost everyone with asthma is prescribed a short-acting beta-agonist (SABA) like albuterol. These inhalers work quickly to relax the muscles around the airways, providing rapid relief during symptoms or before exercise. They're sometimes called "rescue" or "reliever" inhalers because they're used on an as-needed basis.

If you need your rescue inhaler more than twice a week, it's a sign that your asthma needs better long-term control.

Step 2: Inhaled Corticosteroids (ICS)

The cornerstone of asthma control for anyone beyond the mildest form. Inhaled corticosteroids — such as fluticasone, budesonide, beclomethasone, and mometasone — reduce inflammation in the airways when used daily. They don't provide instant relief like a rescue inhaler; instead, they work over days to weeks to bring chronic inflammation under control.

For many people with mild to moderate asthma, a low or medium dose ICS is enough to achieve good control.

Step 3: ICS Combined With a Long-Acting Bronchodilator

When an ICS alone isn't sufficient, a long-acting beta-agonist (LABA) is often added. LABAs — such as salmeterol and formoterol — keep the airways open for 12 hours or more. They're almost always used in combination with an ICS (never alone, as using a LABA without a corticosteroid has been associated with increased risk).

Common combination inhalers include fluticasone/salmeterol, budesonide/formoterol, and mometasone/formoterol.

Step 4: Medium to High-Dose ICS/LABA Combinations

If symptoms remain uncontrolled on a low-dose combination, the ICS dose may be increased to medium or high. Additional medications may be added, including:

Leukotriene modifiers (such as montelukast) — oral tablets that block inflammatory chemicals called leukotrienes. They're particularly helpful for people with allergic asthma or exercise-induced symptoms.

Long-acting muscarinic antagonists (LAMA) — such as tiotropium, originally developed for COPD but now approved as add-on therapy for asthma. They provide additional bronchodilation through a different mechanism.

Theophylline — an older oral bronchodilator that's used less commonly today due to its side effect profile, but can still be helpful in some cases.

Step 5: Biologic Therapies

For people with severe asthma that remains uncontrolled despite high-dose ICS/LABA combinations, biologic therapies represent a newer class of treatment. These are injectable medications given every few weeks that target specific molecules involved in the inflammatory process:

Anti-IgE (omalizumab) — for severe allergic asthma. Anti-IL-5 (mepolizumab, reslizumab) and anti-IL-5 receptor (benralizumab) — for severe eosinophilic asthma. Anti-IL-4/IL-13 (dupilumab) — for moderate to severe eosinophilic asthma or oral corticosteroid-dependent asthma. Anti-TSLP (tezepelumab) — for severe asthma across multiple inflammatory types.

Biologics have been transformative for some patients, dramatically reducing exacerbations and improving quality of life. However, they're expensive, require regular injections, don't work for everyone, and are typically reserved for people who've failed to achieve control with other therapies.

Oral Corticosteroids

Short courses of oral corticosteroids (such as prednisone) are sometimes needed to manage severe flare-ups. However, long-term daily use of oral steroids carries significant side effects — including weight gain, bone thinning, diabetes, high blood pressure, cataracts, and immune suppression — and doctors work hard to minimise or eliminate their use wherever possible.

Living With Moderate to Severe Asthma

Day-to-day life with poorly controlled asthma involves a level of uncertainty and limitation that people with milder forms may not fully appreciate. Some of the most common challenges include:

Unpredictability. You can feel fine one moment and be struggling to breathe the next. This unpredictability makes it difficult to plan ahead — whether that's committing to social events, taking on physical tasks, or travelling somewhere new.

Sleep disruption. Night-time symptoms — coughing, wheezing, or waking up feeling short of breath — are common in moderate to severe asthma and can lead to chronic sleep deprivation. The fatigue that follows affects every aspect of daily life.

Activity limitation. Exercise becomes complicated. Many people with poorly controlled asthma gradually reduce their physical activity to avoid triggering symptoms, which can lead to deconditioning, weight gain, and a cycle of worsening fitness and worsening symptoms.

Medication burden. Multiple inhalers, oral medications, and possibly injectable biologics — each with their own schedule, technique, and side effects — can make the daily treatment routine feel overwhelming.

Emotional impact. Anxiety about when the next flare-up will hit, frustration with treatments that don't work well enough, and the social isolation that can come from avoiding triggers all take a toll on mental health. Depression and anxiety are more common in people with poorly controlled asthma than in the general population.

Financial costs. Asthma medications — especially newer biologics and brand-name inhalers — can be expensive even with insurance. The cumulative cost of medications, doctor visits, emergency room trips, and missed work adds up.

Some practical strategies that people with moderate to severe asthma find helpful:

Have an asthma action plan. Work with your doctor to create a written plan that outlines what to do when symptoms worsen — which medications to adjust, when to use your rescue inhaler, and when to seek emergency care. Having a clear plan reduces anxiety and helps you respond quickly.
Track your symptoms. Keeping a record of daily symptoms, rescue inhaler use, and peak flow readings (if you have a peak flow meter) can help you and your doctor identify patterns and adjust treatment.
Check your inhaler technique regularly. Even experienced inhaler users can develop bad habits over time. Have your technique checked at least once a year.
Get vaccinated. Annual flu vaccination and staying up to date with pneumococcal and COVID-19 vaccinations is particularly important for people with asthma, since respiratory infections are a major trigger for flare-ups.
Address your environment. If allergens are a trigger, practical steps like dust mite covers for bedding, HEPA air filters, and keeping windows closed during high pollen days can make a meaningful difference.

Asthma in Adults: Why It Can Be Different

Most people think of asthma as a childhood condition — and it's true that the majority of cases are diagnosed before age 18. But adult-onset asthma is more common than many people realise, and it tends to behave differently.

Adults who develop asthma later in life are less likely to have allergic triggers and more likely to have persistent, harder-to-control disease. They're also more likely to have non-eosinophilic inflammation, which doesn't respond as well to standard corticosteroid-based treatment.

Women are more likely than men to develop asthma in adulthood, and hormonal factors — including pregnancy, menstruation, and menopause — can influence asthma severity. Occupational exposures can also trigger asthma for the first time in adults who had no prior history.

Because adult-onset asthma is less commonly associated with the "classic" allergic pattern, it can take longer to diagnose and may require a different treatment approach. If you developed asthma as an adult and feel that standard treatments aren't working well, discussing the specific nature of your asthma with a specialist is worthwhile.

The Role of Clinical Research

Despite decades of progress, there are still significant gaps in asthma treatment. Inhaled corticosteroids — the backbone of asthma therapy — have been in use since the 1970s. While biologics have expanded options for severe asthma, they're expensive, require injections, and don't work for every patient or every type of asthma.

What's missing are effective oral medications that can help people whose asthma isn't well controlled on inhaled treatments alone — without the side effects of oral corticosteroids. This is exactly the kind of gap that clinical research is working to fill.

Research studies are currently evaluating new investigational approaches to asthma management, including oral medications designed to target the inflammatory pathways involved in moderate to severe disease. These studies give people an opportunity to access potential new treatments before they're widely available, while contributing to the scientific understanding of asthma.

A clinical research study is currently enrolling adults aged 18 and older who have been diagnosed with asthma for at least one year and use a daily corticosteroid inhaler. The study is evaluating an investigational oral medication for asthma that is not well controlled despite current treatment. Participation includes study-related care and medication at no cost, and compensation may be provided.

See if you may qualify for an asthma clinical research study →

What Does Participating in a Clinical Research Study Involve?

If you've never considered a clinical research study before, it's natural to have questions about what it involves.

Screening. You'll answer questions about your asthma history, current medications, and overall health to see if you meet the study's eligibility criteria. This often starts with a brief online questionnaire.

Informed consent. Before enrolling, the research team will explain everything about the study — its purpose, what you'll be asked to do, the potential benefits and risks, and your rights as a participant. You'll have as much time as you need to ask questions and decide.

Study visits. Depending on the study, you'll attend scheduled visits at a research site. These might include physical exams, lung function tests (spirometry), blood and urine tests, electrocardiograms, and questionnaires about your symptoms and quality of life. The number and frequency of visits depends on the study protocol.

Study medication. Participants may receive the investigational medication or a placebo (an inactive substitute). In many asthma studies, you'll continue taking your usual asthma medications alongside the study treatment — you won't be asked to stop your current care.

No cost. Study-related visits, procedures, tests, and medication are provided at no cost to participants. Compensation for your time and travel may also be available.

Voluntary. You can withdraw from a study at any time, for any reason, without it affecting your regular medical care.

All clinical research studies are reviewed and approved by an independent ethics committee before they begin. The safety and wellbeing of participants is the top priority.

Frequently Asked Questions About Asthma

Is asthma a lifelong condition?

For most people, yes. Asthma is a chronic condition that doesn't go away, though its severity can change over time. Some children with asthma experience improvement or even apparent remission in adolescence, though symptoms can return later in life. In adults, asthma tends to be persistent and requires ongoing management.

Can asthma be cured?

There is currently no cure for asthma. Treatment focuses on controlling inflammation, managing symptoms, and preventing flare-ups. Clinical research continues to explore new approaches that may one day change this.

What's the difference between asthma and COPD?

Both cause breathing difficulties, but they're different conditions. Asthma typically starts earlier in life, involves reversible airway narrowing, and is often linked to allergies. COPD usually develops later (most commonly in smokers), involves permanent structural damage to the lungs, and is not fully reversible. Some people have features of both, called asthma-COPD overlap.

What is a corticosteroid inhaler?

A corticosteroid inhaler (also called an ICS or controller inhaler) delivers a small dose of anti-inflammatory medication directly to your airways. Used daily, it reduces the chronic inflammation that underlies asthma. Common examples include fluticasone, budesonide, and beclomethasone. It's different from a rescue inhaler, which provides quick relief from acute symptoms.

Why does my asthma get worse at night?

Nocturnal asthma is common and may be caused by several factors: lying down can change lung mechanics and increase exposure to allergens in bedding (dust mites); natural hormone fluctuations during sleep can affect airway inflammation; GERD (acid reflux) is worse when lying flat and can irritate the airways; and the body's natural anti-inflammatory processes may dip overnight. If night-time symptoms are frequent, it's usually a sign that your asthma isn't well controlled.

Is it safe to exercise with asthma?

In most cases, yes — and in fact, regular physical activity is encouraged. Exercise improves cardiovascular fitness, strengthens respiratory muscles, and can help with overall asthma management. If exercise triggers your symptoms, your doctor may recommend using your rescue inhaler before activity, warming up gradually, or avoiding exercising in very cold or dry air. The goal is to manage exercise-related symptoms, not to avoid exercise entirely.

What should I do during an asthma attack?

Follow your asthma action plan if you have one. Use your rescue inhaler immediately — typically 2 to 4 puffs. Sit upright and try to stay calm. If your symptoms don't improve within 15 to 20 minutes, or if you're struggling to speak, your lips or fingernails turn blue, or you feel like you can't get enough air, seek emergency medical help immediately.

How is severe asthma different from mild asthma?

Severity is determined by how much treatment is needed to control symptoms and how well that treatment works. Mild asthma can usually be managed with a rescue inhaler and possibly a low-dose ICS. Severe asthma remains uncontrolled even on high-dose ICS/LABA combinations and may require biologic therapy, oral corticosteroids, or other advanced treatments. Severe asthma also carries a higher risk of life-threatening flare-ups.

Taking the Next Step

If you've been living with asthma that isn't well controlled — despite using your daily inhaler, avoiding triggers, and following your doctor's advice — you're not alone, and you're not out of options.

Clinical research is actively working to develop new approaches for people in exactly this situation. A study is currently enrolling adults aged 18 and older who use a daily corticosteroid inhaler and still experience symptoms. Study-related care and medication are provided at no cost, and compensation may be available.

Check your eligibility for an asthma clinical research study →

This article is for informational purposes only and is not intended as medical advice. Always consult your doctor before making decisions about your health or treatment plan.

Last updated: February 2026